Endotracheal tube with asymmetric balloon

ABSTRACT

Blood flow in the aorta and pulmonary artery of a mammal, most typically a human, is measured volumetrically by a non-invasive, ultrasound apparatus. The apparatus (10) comprises a tracheal tube or probe with of flexible tubing (11) having a transducer assembly (21) mounted at one end the tube. The transducer assembly (21) is disposed to transmit ultrasound in selected directions. Electrical conductors (24) extend the length of the probe from the transducer assembly. Improved means is provided to positively locate the probe in the trachea and to urge the ultrasound transducer assembly (21) into intimate contact with the inner wall of the trachea. The improved location and urging means comprises a single inflatable asymmetric balloon cuff member (29) mounted on the tube (11) in proximity to and above the transducer assembly (21) and extending around the entire periphery of the tube, the balloon being mounted on the tube such that when inflated the balloon sealingly engages the tracheal wall while urging the transducer assembly into contact with the inner wall of the trachea. 
     The asymmetric balloon cuff is conveniently formed in a mold prepared by angularily sectioning the conical portion of a pair of funnel shaped mold forms at equal angles relative to the central axis thereof, rotating one of the sectioned funnel forms 180° about the axis and then joining the two forms at the section plane to form the balloon cuff mold form.

BACKGROUND OF INVENTION

1. Field of Invention

Measurement of cardiac output is crucial in the care of critically illpatients such as patients with multiple trauma, patients in overwhelmingsepsis, and patients with acute myocardial infarction. In the case ofpatients with acute myocardial infarction, there is a worseningprognosis with decrease in cardiac output. Knowledge of the cardiacoutput provides information useful in determining the clinical state ofa given patient and in rationally planning therapy for the patient. Suchinformation is not contained in the usually measured vital signs. Forexample, a low mean arterial pressure with elevated pulse does notadequately distinguish between cardiogenic and septic shock, thetreatments for which are quite different. Consequently, a method thatdistinguishes between cardiogenic and septic shock would be important inplanning appropriate therapy. The measurement of cardiac output, in thiscase, would provide valuable information that would allow an appropriatediagnosis to be made.

2. Prior Art

The importance of knowing cardiac output has led to many methods for itsdetermination. The most commonly used method in widespread clinical useis thermodilution. In the thermodilution method a catheter is placedinto the central venous circulation, usually by percutaneous entry intothe internal jugular or subclavian vein. A balloon at the end of thecatheter is inflated, and the normal flow of blood is employed to directthe tip of the catheter into the pulmonary artery. Measurement ofcardiac output is made by observing the dissipation of a temperaturepulse, usually a bolus of iced sterile water or saline solution. As isevident, the method cannot be used without invasion of the vasculartree. Indeed, the catheter is threaded through the heart and the heartvalves. Flow direction is not entirely reliable. In certain patientsaccess to the pulmonary artery is impossible. During placement of thecatheter cardiac arrhythmias are not uncommon. Other complicationsinclude sepsis, thrombosis of the central veins, emboli, and fatalrupture of the pulmonary artery. Other disadvantages of the techniqueinclude lack of continuous information about the cardiac output andchance location of the catheter, such as in an unfavorable pulmonaryartery branch, with erroneous values for the cardiac output. Analysis ofthe error inherent in the measurement of blood flow by thermodilutionhas revealed a standard deviation of 20-30%.

Measurement of cardiac output has also been done by the indocyaninegreen dye technique, which suffers from several disadvantages. Thetechnique is cumbersome, it requires the placement of an arterialcatheter, is not accurate at low levels of cardiac output and isdifficult to use for repeated measurements in the same patient.Complications include catheter site hematoma, sepsis from the catheter,thromboses of the artery containing the indwelling catheter, andpseudoaneurysm formation at the site of arterial puncture.

The Fick method is based on the measurement of oxygen consumption. It isbest used in awake, alert, stable patients not requiring respiratorysupport on a ventilator. The method requires invasion of the pulmonaryartery in order to obtain samples of mixed venous blood fordetermination of the oxygen content. Like the indocyanine green dyetechnique, an arterial catheter must be placed for sampling of arterialblood for oxygen content with the disadvantages mentioned above.

Transcutaneous ultrasound has also been used. Ultrasound transducers areplaced externally on the body at the suprasternal notch. Under the mostsanguine circumstances, at least 10% of patients cannot have theircardiac outputs measured in this way. Many difficulties with thisapproach have been reported: repeated measurements may lead to varyinglocation of the sample volume that is scanned, there are changes in theangle of intersection of the ultrasound beam with the axis of thevessel, capability for continuous measurement of the cardiac output isnot available, and other major thoracic vessels may interfere with theDoppler ultrasound signals. Further, the method is not feasible in manyimportant clinical settings in which the patients are not cooperative orare in the operating room, where the suprasternal notch may not beaccessible.

Because of these difficulties, an implantable, removable Dopplerultrasound device for measurement of the cardiac output has beendeveloped for direct attachment to the aorta. The device requires amajor, operative, invasive intervention, such as splitting the sternumor removal of a rib to enter the chest cavity, for placement of thedevice directly on the wall of the aorta. Removal of the device alsorequires surgical intervention. If the device were to be lost in a majorbody cavity, a major surgical procedure would be required.

Measurement of cardiac output by continuous or single breath,gas-washout has been attempted, but is not used in standard clinicalmedicine. Such methods require many approximations of lung function inmodeling the system. Time consuming numerical analysis is required. Inone study, measurement of cardiac output in anesthetized patients usingargon and freon during passive rebreathing was shown to provide lowercardiac outputs than a simultaneously performed Fick determination. Theauthors concluded that the method caused significant disturbances ofhemodynamics and was therefore not suitable for widespread use.

Indirect measurements include the pulse, blood pressure, and urineoutput, but these measurements are not specific for cardiac output. Forexample, in the presence of acute renal failure, urine output cannot becorrelated with perfusion of major organs.

In the patent art, Tickner, U.S. Pat. No. 4,316,391 discloses anultrasound technique for measuring blood flow rate. Colley et al., U.S.Pat. No. 4,354,501, discloses an ultrasound technique for detecting airemboli in blood vessels. Numerous patents disclose catheters or probes,including Calinog, U.S. Pat. No. 3,734,094, Wall, U.S. Pat. No.3,951,136, Mylrea et al., U.S. Pat. No. Re. 31,377, Perlin, U.S. Pat.Nos. 4,304,239; 4,304,240 and 4,349,031, Colley et al., U.S. Pat. No.4,354,501 and Furler, U.S. Pat. No. 4,369,794.

U.S. Pat. No. 4,331,156 discloses an esophageal cardiac pulse probewhich utilizes a closed end lumen with a pressure transmitting fluidtherein to transmit sounds from the heart and lungs to an externaltransducer.

In U.S. Pat. Nos. 4,671,295 and 4,722,347 there is described a methodand apparatus for measuring cardiac output which comprises placing anultrasound transducer in great proximity to the ascending aorta of theheart of the mammal by passing a probe carrying the transducer into thetrachea and transmitting ultrasound waves from the transducer toward thepath of flow of blood in the ascending aorta. The probe can be passedthrough the nasal or oral cavity, past the epiglottis into the tracheaor, in the case of patients who have had a tracheostomy, directly intothe trachea through the surgical opening. The reflected ultrasound wavesare received by the transducer and the average Doppler frequencydifference between the transmitted waves and the reflected waves ismeasured. The cross-sectional size or area of the ascending aorta at thepoint of ultrasound reflection is calculated and the volumetric bloodflow rate is determined from such measurements. The method and apparatusfor measuring cardiac output described in U.S. Pat. Nos. 4,671,295 and4,722,347 provides for the determination of the cardiac output in a waythat is accurate, noninvasive, continuous, inexpensive and suitable foruse in those patients whose cardiac output measurement is most critical.

SUMMARY OF THE INVENTION

The present invention comprises an improvement in the apparatus of U.S.Pat. Nos. 4,671,295 and 4,722,347. In one embodiment the inventioncomprises an improved tracheal probe for use in determining blood flowin a major discharge artery, including the pulmonary artery and theaorta, of a mammalian heart, which comprises:

a. a flexible tube having a length sufficient to extend from the oral ornasal cavity of the mammal or from the surgical tracheal opening throughthe trachea to the bifurcation thereof,

b. an ultrasound transducer assembly mounted to the tube in proximity tothe distal end thereof, and

c. means mounted on the tube for urging the transducer into contact withthe inner wall of the trachea, the improvement comprising that saidurging means comprises a single asymmetric inflatable balloon cuffmember in proximity to and above the transducer assembly and extendingaround the entire periphery of the tube, said single asymmetric balloonbeing mounted on the tube such that when inflated the balloon sealinglyengages the tracheal wall while urging the transducer into contact withthe inner wall of the trachea.

In another aspect of the invention the inventive balloon cuff may beused with any device, mounted on a catheter or flexible tube which isinserted into a mammalian body passageway and threaded through thepassageway to a point in the body where it is desired that the devicemounted on the catheter or flexible tube contact the side wall of thebody passageway.

A still further aspect of the invention comprises a method formanufacturing the balloon cuff mold by angularly sectioning the conicalportion of a pair of funnel shaped mold forms at equal angles relativeto the central axis thereof, rotating one of the sectioned funnel forms180° about the axis and then joining the two forms at the section planeto produce the balloon cuff mold form.

The asymmetric balloon mold and the balloon molded therefrom are furtheraspects of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a front-to-back vertical sectional view of the upper portionof the human body showing the oral cavity and the pathway through thetrachea to the bifurcation thereof. The heart is shown in lateral orside view. The tracheal probe of the invention is shown in position inthe trachea with the transducer assembly contacting the tracheal wall inproximity to the ascending aorta.

FIG. 2 is a front view of the ascending aorta, the trachea, includingthe bifurcation thereof, and the esophagus and shows the closerelationship between the tracheal and the ascending aorta.

FIG. 3 is a horizontal sectional view of the trunk of a human taken atthe level of the tracheal bifurcation and shows the close relationshipbetween the trachea and the ascending and descending aorta and thepulmonary arteries.

FIG. 4 is a perspective view from the left side of the tracheal probe ofthe present invention with the balloon inflated.

FIG. 5 is a front view of the preferred balloon cuff of the invention.

FIG. 6 is a left side view of the preferred balloon cuff of theinvention.

DESCRIPTION OF PREFERRED EMBODIMENT

Reference is made to the disclosure of U.S. Pat. Nos. 4,671,295 and4,722,347 for a detailed description of the theory and operation of thetracheal probe and for modifications, not relevant to the presentinvention, which may be employed. The present disclosure should beconsidered in conjunction with those two patents to the extent necessaryto fully understand the invention.

The apparatus of the preferred embodiment consists of a probe with apiezoelectric transducer mounted at one end and electrical conductorsextending the length of the probe for connection to conventionaldirectional pulsed or continuous wave Doppler ultrasound hardware, suchas that described by Hartley et al. in the Journal of AppliedPhysiology, October 1974, and by Keagy et al. in the Journal ofUltrasound Medicine, August 1983. Modifications to the signal output canbe made to display blood flow volume rate, aorta or other vesseldiameter, blood velocity and other selected displays.

The probe 10 is shown in FIGS. 1 and 6. Probe 10 consists of flexibleplastic tubing 11. The length must be sufficient to extend from outsidethe body to the vicinity of the heart through the trachea, enteringeither through the nasal or oral cavity or through a surgical opening inthe case of patients who have had a tracheotomy. The particular probeshown in FIG. 1 is adapted for oral insertion.

Near the distal end of the probe a transducer assembly 21, suitablycomprising one or more piezoelectric transducers and associated lenses,is mounted on the exterior of tubing 11. Transducer assembly 21 is usedto collect Doppler data for velocity calculation and to collect data forcalculation of the diameter of the artery at the point of velocitymeasurement. Electrical conductors 24, extend the length of tube 11 forconnection of transducer assembly 21 to conventional Doppler ultrasoundhardware.

An acoustical gel, such as Aquasonic 100, a trademark of and availablefrom Park Laboratories, Orange, N.J., may be placed on the surface ofthe transducer assembly to fill in the small, irregular space or spacesbetween the transducer lens and the trachea that remain because of theirregularly shaped and relatively non-deformable cartilaginous innersurface of the trachea when the lens engages the trachea. Alternatively,a generous application of a conventional lubricant, such as a anestheticlubricant, commonly used when inserting a tracheal tube can be relyedupon to provide whatever gap filling is necessary.

An understanding of the use of the present invention requires someunderstanding of mammalian anatomy and in particular an understanding ofthe human anatomy, which is shown in pertinent portion in FIGS. 1, 2 and3. The apparatus is used by placing the ultrasound transducer assembly21 in great proximity to the arterial vessel in which blood flow is tobe measured, most typically the ascending aorta of a human, withoutsurgery or other invasive techniques. The method relies on theanatomical discovery or fact that the ascending aorta is locatedadjacent the trachea just above the bifurcation thereof, and that atransducer placed in the trachea can be directed toward the ascendingaorta and accurate blood flow measurements made without significantinterference. With reference to FIGS. 1, 2 and 3, access to the trachea,T, of a human, H, can be had in accordance with standard medicalpractice through the nasal cavity, N, or the oral cavity, O, past theepiglottis, E, and into the trachea, T. Access can also be had through asurgical opening at the suprasternal notch, S, in the case of patientswho have had a tracheotomy. The ascending aorta, A, and the pulmonaryartery, PA, are located in great proximity to the trachea, T, just abovethe bifurcation, as best seen in FIGS. 2 and 3.

Consequently, a transducer or transducers placed in the trachea as shownin FIG. 1 can be directed to transmit and receive ultrasound wavesthrough the wall of the trachea and through the wall of the ascendingaorta or the pulmonary artery to be reflected by the blood flowing inthe selected artery and, due to the movement of the blood, cause aDoppler shift in the frequency of the reflected waves as compared to thefrequency of the transmitted waves. The ultrasound waves are alsoreflected by the near and far walls of the artery and such reflectioncan be used for diameter measurement of the artery.

Means is provided to positively locate probe 10 in trachea, T, and tourge transducer assembly 21 into intimate contact with the inner wall ofthe trachea.

The disclosed device of U.S. Pat. Nos. 4,671,295 and 4,722,347 utilizesa pair of inflatable balloons to properly position the transducerassembly 21 against the wall of the trachea in proximity to theascending aorta. One such balloon is a donut shaped cuff which positionsthe probe in the center of the trachea and seals the trachea. A secondballoon, located on the back side of the probe behind the transducerassembly, is inflated to urge the transducer assembly against thetracheal wall. This is a complicated construction and it is an object ofthe invention to simplify the construction by utilizing a single ballooncuff, asymmetrically disposed about the axis of the tube 11 when viewedfrom the side, to simultaneously seal the trachea, securely positionprobe 10 in the trachea and urge the transducer assembly 21 against thetracheal wall in proximity to the selected artery.

The asymmetric balloon is designated by the numeral 29 and is shown indetail in FIGS. 4-6. The balloon is made of conventional materials.Suitably it is dip or blow molded. The mold is formed by sectioning apair of cones, suitably funnel shaped cones, at an acute angle relativeto the central axis thereof, rotating one of the cones 180° relative tothe other and joining the two cones alone the section line. Theresulting mold form has the shape of the balloon, shown in FIGS. 4 and5. The balloon has a pair of sleeves 30 formed by the funnel shaft formating the cuff to tubing 11 over an opening to an inflation lumen 31which runs along tube 11. Circumferential line 32 defines the matingedges of the two cones. The angle of the conical section relative to thecentral axis of the cone is designated θ in FIG. 6. The angle of theconical surfaces relative to the central axis of the cone is designatedΦ in FIG. 5. Neither angle θ nor angle φ are critical and the selectionof angle will generally be determined by the desirability of complyingwith industry standards regarding the overall dimensions of tracheasealing balloons. Without limitation, however, angle θ may suitably bein the range of 50°-75°, preferably 60°-65° and angle Φ may suitably bein the range of 10°-30°, preferably about 15°-20°.

As shown in FIG. 5, the preferred balloon when viewed from the front issymmetric about the plane the passing through axis line 40 andperpendicular to the page. Preferably when the balloon is mounted ontube 11 this line of symmetry is aligned with the plane which passesthrough the central axis of tube 11 and the center of transducerassembly 21. However, the two planes may be offset slighty withoutdeparting from the invention hereof.

The asymmetry of the balloon when viewed from the side is such that wheninflated the balloon has a bulge 42 on the back side thereof on theportion of the cuff closest to the transducer and a second bulge 43 onthe front side of the probe of the portion of the cuff furthest from thetransducer.

The structure of balloon 29 allows a single balloon to accomplish thefunctions of the dual balloon system disclosed in U.S. Pat. Nos.4,671,295 and 4,722,347. The use of mated angularly sectioned cones toprovide a mold configuration conferring the desired asymmetry in theballoon allows the mold to be prepared very inexpensively. Thesefeatures provide significant advantages over the dual balloon system ofU.S. Pat. Nos. 4,671,295 and 4,722,347.

In use probe 10 is placed to locate transducer assembly 21 in thetrachea, T, pointing toward the selected artery, suitably as theascending aorta. The position of probe 10 and transducer assembly 21 canbe adjusted until the maximum Doppler shift is obtained and the positioncan also be checked or confirmed by X-rays to insure placement foroptimum data collection. In general, transducer assembly 21 should belocated just above the tracheal bifurcation and directed toward theselected artery.

For ventilation purposes it is necessary to seal the trachea. It is alsoimportant that the transducer assembly 21 be held in position so that itis not moving about within the trachea while measurements of cardiacoutput are being taken. Use of a traditional symmetric balloon willforce the distal end of the probe away from the wall of the trachea andtoward the center thereof, thus requiring a second means for urging thetransducer assembly against the tracheal wall. The asymmetric balloon29, however, complements the natural curvature of tube 10, shown in FIG.4, so that it effectively seals the trachea and holds the tube in placewhile simultaneously urging the transducer assembly 21 into acousticcontact with the tracheal wall. Inflation of asymmetric balloon 29 isaccomplished with using conventional procedures for inflating anendotracheal tube balloon.

In other respects the endotracheal tube 10 is constructed in accordancewith recognized standards for construction of endotracheal tubes. Inparticular, the distal end suitably is provided with a standard bevelopening 33 and oppositely directed Murphy eye 34 manufactured inaccordance with ANSI standards.

After proper placement of probe 10 and connection with the electricalhardware, ultrasound signals are generated and the Doppler shift ismeasured for velocity calculation and data for calculating the diameterof the artery is also collected. These data are used to determine thevolumetric rate of blood flow as set forth in detail in U.S. Pat. Nos.4,671,295 and 4,722,347.

A large number of patients who require continuous measurement of cardiacoutput have significant associated clinical problems. Often suchpatients have multiple systems organ failure, overwhelming sepsis,significant trauma to many major organ systems, decompensated congestiveheart failure, or major myocardial infarction. Such patients often havean endotracheal tube in place because of such problems. For example, inpatients having a major surgical procedure, use of general anesthesiarequires the presence of an endotracheal tube for the maintenance of thepatient's airway. In the case of patients having open heart surgery, anendotracheal tube is often in place for the night following surgery.Patients suffering major trauma are routinely intubated followingsignificant thoracic trauma, significant head injury, or multipleabdominal injuries. Patients in multiple systems organ failure, septicshock, or hemorrhagic shock have endotracheal tubes in place to assistventilation during acute decompensation and in the immediateresuscitation phase. Patients with significant burn injuries frequentlyrequire endotracheal intubation during initial resuscitation, fortransportation to a burn center, and for thermal injury to therespiratory system. Patients with decompensated congestive heart failureleading to pulmonary decompensation with pulmonary accumulation of fluidrequire endotracheal intubation. Such patients may have underlyingmyocardial infarction, cardiomyopathy, cardiac valvular disease, orchronic congestive heart failure. In many of these examples,stabilization of the cardiovascular system is a prerequisite for removalof the tracheal tube. Consequently, use of an endotracheal probe inaccordance with the present invention represents no further invasion ofany body cavity. Thus, in the case of patients already having a trachealtube in place, as well as in patients in which no tracheal tube has beenpreviously placed for other reasons, the present invention provides formeasurement of cardiac output at optimum locations without majorsurgical procedure or invasion of a closed body system. No invasion of amajor body cavity, not routinely in communication with the externalenvironment, is required. No major or minor surgical procedure isrequired. No indwelling foreign body is necessary in the vascularsystem, a major body cavity, or in a major organ. No dye or radioactivesubstance is necessary for the measurement to be performed, and no airemboli are introduced. Continuous monitoring is also possible.

While the foregoing description of applicants' invention is directed tomeasurement of cardiac output in the ascending aorta, measurement ofblood flow in the descending aorta, the right pulmonary artery and theleft pulmonary artery can also be made with the applicants' apparatus.Moreover, the inventive balloon cuff can also be usefully employed withother devices located on catheters or other flexible tubes and insertedthrough a tubular body passageway to a point where it is desired thatthe device contact the wall of the passageway to effectively operate thedevice. For instance, a balloon cuff of the invention may be used toposition the end of a laser angioplasty device of the type disclosed inU.S. Pat. No. 4,685,458 adjacent to a plaque deposit in an artery.

I claim:
 1. A tracheal probe for use in determining blood flow rate in amajor discharge artery, including the pulmonary artery and the aorta ofa mammalian heart, comprising:a. a flexible tube having a longitudinalaxis and a length sufficient to extend from the oral or nasal cavity ofthe mammal or from a surgical tracheal opening through the trachea tothe bifurcation thereof, b. an ultrasound transducer assembly mounted tothe tube in proximity to the distal end thereof and, c. means mounted onthe tube for urging the transducer assembly into acoustic contact withthe inner wall of the trachea, the improvement comprising that saidurging means comprises a single inflatable balloon cuff memberasymmetric about said tube axis when inflated in proximity to andproximal along said tube with respect to the transducer assembly andextending around the entire periphery of the tube, said singleasymmetric balloon cuff member, being mounted on the tube such that wheninflated the balloon cuff member sealingly engages the tracheal wallwhile urging the transducer assembly into acoustic contact with theinner wall of the trachea.
 2. The tracheal probe of claim 1 wherein thedistal end of the tube is open to provide for ventilation of the mammalthrough the tube.
 3. The probe of claim 1 wherein the said cuff memberwhen inflated is generally symmetric about a first plane which passesthrough the axis of the tube and through said transducer and said cuffmember is asymmetric about a second plane generally perpendicular tosaid first plane, said second plane defining front and back sides of theprobe, the side bearing the transducer assembly being the front side,the asymmetry of the cuff members causing the portion of the cuffclosest to the transducer assembly to be enlarged on the back side ofthe probe relative to the front side thereof and causing the portion ofthe cuff member furthest from the transducer assembly to be enlarged onthe front side relative to the backside of the probe.
 4. A probe havingan elongated flexible member having an axis and an axis and a devicemounted thereto whereby the device may be inserted into a mammallianbody and passed through a tubular passageway in the body to a pointwhere it is desired that the device contact the wall of said passagewayto effectively operate the device, the improvement comprising that thesaid elongated flexible member includes an inflatable balloon cuffmember asymmetric about the axis of said flexible member in proximity toand proximal along said flexible member will respect to the said deviceextending around the entire periphery of the flexible member and meansfor inflating said asymmetric balloon cuff member said balloon cuffmember being mounted on the flexible member such that when inflated theballoon cuff member sealingly engages the wall of the passageway whileurging the said device into contact with the inner wall of saidpassageway.